"Lues maligna" bei insulinpflichtigem Diabetes mellitus. "Lues maligna" in a female patient with diabetes

A 40-year-old female patient with diabetes mellitus presented with multiple erythematous ulcerated nodules and plaques predominantly on the trunk. A few months ago her partner had a small ulcer on the penis. She was HIV negative but showed markedly elevated syphilis serology titers (TPPA titer > 1:20.480, VDRL titer 1:128). The serum glucose levels exceeded 275 mg/dl. After exclusion of neurological involvement, we made the diagnosis of "lues maligna" arising in the setting of diabetes mellitus. The patient was treated with 2.4 million units benzathine penicillin intramuscularly weekly for three weeks. Simultaneously, diabetes therapy was improved with insulin injections. The syphilitic lesions cleared rapidly. In the follow-up VDRL titer was negative. "Lues maligna" is an unusual ulcerative variant of secondary syphilis which has been observed more frequently in HIV-infected patients in the last years. The occurrence of this aggressive variant in the clinical setting of diabetes mellitus is extremely rare.

[Secondary syphilis with ocular involvement in a 77-year-old man]

A 77 year old man complained of vision loss and presented psoriasiform skin manifestations. A bilateral panuveitis was observed and after extensive investigation including vitrectomy the patient was diagnosed with secondary syphilis with ocular involvement. Syphilis has shown an increasing incidence in Sweden especially within the group of men who have sex with men. This case report reminds us of the diversity of symptoms which syphilis may present and the importance of PCR to demonstrate Treponema pallidum.

Extensive annular verrucous late secondary syphilis

We report an illustrative case of an apparently healthy 38-year-old man with a past history of alopecia universalis who developed extensive, slightly pruritic, infiltrated annular verrucous lesions of the scalp, perioral, lumbar, perianal and genital areas over a 6-month period. The combination of an unusual clinical presentation, positive syphilis serology and rapid response to penicillin therapy was consistent with a diagnosis of extensive annular and verrucous late secondary syphilis. We present this case to illustrate a rare and potentially misleading clinical feature of late secondary syphilis, a disease considered to be of the past but still present in today's practice.

Lues maligna

The incidence of syphilis in the UK is rising, particularly in HIV-positive men. We describe a Caucasian, HIV-negative woman who presented with secondary syphilis taking the form known as lues maligna. She also demonstrated the prozone phenomenon whereby the rapid plasmin reagin test was negative, but the Venereal Disease Research Laboratory and Treponema pallidum haemagglutination tests were positive.

Seronegative secondary syphilis in an HIV-infected patient

Recently, increased rates of syphilis among gay men have been observed in American and European cities. It is important to establish the diagnosis because syphilis facilitates HIV transmission during the primary and secondary stages when sores are open on the skin. However the diagnosis can present a dilemma as negative reactions to serological tests may be observed in AIDS patients. We report here such a case in which the diagnosis was established on dark field examination.

Subfamily I Treponema pallidum repeat protein family: sequence variation and immunity

A 12-membered Treponema pallidum repeat (Tpr) protein family has been identified in T. pallidum subsp. pallidum, the causative agent of syphilis. The subfamily I Tpr proteins (C, D, F, and I) possess conserved sequence at the N- and C-termini and central regions that differentiate the members. These proteins may be important in the immune response during syphilis infection and in protective immunity. Strong antibody responses have been observed toward some of the subfamily I Tpr proteins during infection with different syphilis isolates. Some sequence variation has also been identified in one subfamily I Tpr member, TprD, among T. pallidum subsp. pallidum isolates. In this study, we examined sequences in the remaining subfamily I Tpr proteins among strains. Both TprF and TprI were conserved among T. pallidum subsp. pallidum isolates. While some heterogeneity was identified in TprC. We further examined the immune response and protective capacity of TprF protein in this paper. We demonstrate that the N-terminal conserved region of the subfamily I Tpr proteins elicits strong antibody and T-cell responses during infection, and immunization with this region attenuates syphilitic lesion development upon infectious challenge.

Secondary syphilitic lesions

An important theme that emerges from all early historical accounts is that in addition to the decreased virulence of Treponema pallidum, the incidence of secondary syphilis has decreased drastically over the past three centuries. Even in the early 20th century, most syphilologists were of the opinion that the disease had undergone changes in its manifestations and that they were dealing with an attenuated form of the spirochete. Such opinions were based primarily on the observations that violent cutaneous reactions and fatalities associated with the secondary stage had become extremely rare. The rate of primary and secondary syphilis in the United States increased in 2002 for the second consecutive year. After a decade-long decline that led to an all-time low in 2000, the recent trend is attributable, to a large extent, by a increase in reported syphilis cases among men, particularly homosexual and bisexual men having sex with men. The present review addresses the clinical and diagnostic criteria for the recognition of secondary syphilis, the clinical course and manifestations of the disease if allowed to proceed past the primary stage of disease in untreated individuals, and the treatment for this stage of the disease.

[Syphilis maligna in an HIV-negative patient]

A 21-year-old patient with a history of drug addiction presented with generalized, centrally-ulcerated papules and haemorrhagic crusts. Initially, differential diagnostic considerations included pityriasis lichenoides et varioliformis acuta and syphilis. Biopsy and serological testing confirmed the latter diagnosis. Syphilis maligna is a rare form of secondary syphilis; symptoms include a papulonecrotic exanthem and general malaise with fevers and wasting. In the past the disease was described in connection with tuberculosis; today it is most often seen in association with HIV.

Detection of Treponema pallidum in skin lesions of secondary syphilis and characterization of the inflammatory infiltrate

BACKGROUND

Syphilis is an ancient sexually transmitted disease. However, the pathogenesis of mucocutaneous lesions of secondary syphilis is not completely understood.

METHODS

We analyzed the presence of Treponema pallidum in formalin-fixed, paraffin-embedded biopsy specimens from mucocutaneous lesions of secondary syphilis using highly sensitive nested polymerase chain reaction (PCR). The inflammatory infiltrates from the same specimens are also characterized using immunohistochemical methods.

RESULTS AND CONCLUSIONS

Ten out of 24 (41.7%) specimens are T. pallidum positive using nested PCR, whereas none of them is T. pallidum positive using traditional silver staining. The presence of T. pallidum in the mucocutaneous lesions indicates that mucocutaneous lesions of secondary syphilis might be caused by direct T. pallidum invasion rather than by an allergic reaction. Furthermore, the majority of inflammatory infiltrating cells are CD45RO-positive T cells and CD68-positive macrophages, suggesting that cellular immunity plays an important role in the host reaction against T. pallidum infection in secondary syphilis.

Aspects histologiques des lésions cutanées de la syphilis secondaire

Syphilis is a sexually transmitted infectious disease, which currently shows a high increase of incidence in HIV negative patients. These patients often seek medical advice at a stage of secondary syphilis, as the lesions of the primary phase may pass unperceived. Very often, the diagnosis is evoked through a cutaneous biopsy, since the clinical presentation is often misleading. Even though the histological signs are not specific, they may suggest the diagnosis, by showing a psoriasiform epidermal hyperplasia with neutrophil exocytosis and a dermal lichenoid infiltrate rich in plasma cells. However, it is important to underline the great polymorphism of these lesions, which can easily vary according to the stage and /or clinical form. It's very important to have a quick and accurate diagnosis, because the lesions are very contagious, but rapidly and completely cured by an early administrated antibiotic treatment.

Secondary syphilis presenting as a lichen planus-like rash

We describe a case of secondary syphilis in a 29-year-old man who presented with a severely pruritic lichen planus-like eruption that mimicked a lichenoid drug eruption histologically. Although uncommon, syphilis should be considered in the differential diagnosis of any lichenoid eruption.

Atypical presentation of syphilis in an HTLV-I infected patient

We report the case of a 44 year-old female, who presented a long-lasting, clinically atypical, secondary syphilis ("malignant syphilis") in the right foot, which started six months before medical evaluation. The patient had a serological diagnosis of HTLV-I infection and syphilis two years before the onset of the skin lesions, following a blood donation. As she believed she was allergic to penicillin, she initially received sulfamethoxazole + trimethoprim, without any improvement of the clinical picture. After failure of this first treatment regimen, she was given penicillin, which promoted complete healing of the lesion. We found evidence that infection by HTLV-I is capable of modifying the clinical course of secondary syphilis.

Clinical Features of Skin Lesions in Rabbit Syphilis: A Retrospective Study of 63 Cases (1999-2003)

Skin lesions in rabbit syphilis are usually diagnostic, but it is occasionally difficult to differentiate these lesions from those of other skin diseases. Skin lesions in 63 cases of rabbit syphilis were analyzed for early and accurate diagnosis. Lesions were found most frequently around the nose (55 cases) followed by the genitalia (22), lips (20), eyelids (12), and anus (10). Sneezing was observed in 33% of cases with nasal lesions. In cases of maternally acquired infection, lesions could be initially found mainly on the face. Rabbits should be examined carefully not only for facial lesions, but also for lesions of the genitalia and anus, locations easily overlooked.

Keratosis lichenoides chronica mimicking verrucous secondary syphilis

Keratosis lichenoides chronica is a rare dermatosis of unknown etiology with a wide variety of cutaneous manifestations. We present a 47-year-old male with a history of progressive and recalcitrant hyperkeratotic and warty plaques, mimicking verrucous secondary syphilis both clinically and microscopically. We review the clinical manifestations, microscopic features, and treatment modalities for this rare and distinctive dermatosis.